The need to ensure continuity of care for adolescents during the transition from pediatric to adult primary care is a notion that is both widely accepted and operationally challenging.
In reality, given the constant volume of adolescent patients growing into adulthood within pediatric practices, transitions to adult medicine typically occur organically. In this article, however, we suggest a methodical approach that encourages the establishment of a formal transition policy that can then be adopted by primary care staff.
Any such policy adoption must be backed by a robust operational process. However, before such a formal process can be explored, it is important to understand the factors that make this process difficult. Interestingly, these same factors also illustrate the importance of perfecting the art of transition.
Challenges of Standardizing Transitions
As Dr. Elaine Cox writes in U.S. News & World Report, many adolescents are ill-equipped to manage their own personal health. Young adults may reach the capacity to do so at different ages. This variation in development is not a reason to delay transferring medical responsibility; rather, it should prompt providers and families to take steps to ensure a smooth transition.
Given that many adolescents begin their relationship with their pediatrician in infancy, they may feel abandoned upon being released from the pediatrician’s panel. This feeling may be compounded during the confusing process of finding a new provider. Moreover, according to an issue brief written for the Lucile Packard Foundation for Children’s Health (LPFCH), 18% of young adults have a special health care need. For this vulnerable group of patients, the process of moving from pediatric to adult medicine can be especially complicated. A 2011 paper in the American Journal of Lifestyle Medicine suggested that 46% of diabetic adolescents reported problems transitioning to adult care, 31% had a lapse of >6 months between their last pediatric visit and their first visit with an adult health care provider, and 11% were completely lost to follow-up. Such gaps in care represent a serious clinical care issue that can be associated with negative and costly outcomes. For this cohort of patients, the process of handoff to adult providers must be meticulous and deliberate.
Reaching the age of 18 years is typically associated with a variety of other changes: high school graduation, new relationships, and organic decoupling from parents as a result of employment or the pursuit of higher education. At a time marked by such changes, personal health care may be the last thing on patients’ minds, so a medical intervention may seem nearly impossible.
Physicians face their own challenges during the transition process. First, they may feel compelled to continue providing care to their patients, given the strong personal relationships that they have developed over the years and their engrained knowledge of their patients’ specific health issues and needs. Furthermore, any formalized strategy threatens to occupy time that the physician could otherwise spend addressing clinical issues. To complicate matters, it may be difficult for a pediatrician’s office to tackle the challenge of standardizing the transition process. The development of a standardized process typically requires collaboration across multiple functional areas. In addition, for many provider groups, developing such a process may involve using their electronic health record (EHR) system and patient-facing resources in new ways.
The complexities mentioned above also represent — somewhat ironically — the very reasons that group practices should adopt an organizational strategy to tackle transitioning patients from pediatric to adult medicine. Without a strategy, providers run the risk of compromising the appropriateness and quality of care, especially given the “medical dividing lines” between pediatricians and adult providers as noted by Dr. Perri Klass in the New York Times. After all, throughout the process of transition, pediatricians should be obligated to educate a patient’s future physician about known health issues.
Below, we offer some guidance around what the operational process could look like.
Proposed Workflow for Standard Pediatric Transition
1. Transition Readiness Evaluation
While the American Academy of Pediatrics (AAP) deems the ideal transition age to be between 18 and 21 years, preparations for the transition should start earlier. The recommended first step is for pediatric office staff to provide the patient and family with a Transition Readiness Evaluation at the end of the 16-year-old physical exam, along with the standard after-visit summary. The purpose of this evaluation is to stimulate thoughts about one’s own health care by asking questions such as:
- Do I know my medical needs?
- Do I know my medications?
- Do I make my own appointments?
2. Transition Discussion
Pediatricians should openly introduce and discuss the transfer of care with patients between the ages of 18 and 21 in the doctor’s office. In certain patient populations, this discussion should occur at an earlier age, particularly if there are questions regarding guardianship and life-skills education. Following these age guidelines is consistent with the AAP’s recommendation and, by allowing a 4-year range, also acknowledges that there may be substantial variation among patients in terms of the readiness to transition, the engagement of family members, the disease burden, and so on.
These conversations must be supplemented with printed or electronic materials that list local adult-medicine physicians. In fact, physician groups that provide care to both children and adults can use this step as a tool to advertise their own providers, thus retaining patients within the system. As noted earlier, patient retention is important for organizations that are reliant on member volume, especially given the various social changes that threaten retention during this age range. The materials should also clearly list the necessary contact information so that patients can relay their provider decisions to the registration department.
3. Patient Decision and Recording
The patient’s choice of adult primary care provider then must be transmitted to the registration department staff, who should be responsible for recording it in the EHR. In this way, a practice can track many such requests in a worklist. An entry into the EHR should be followed by two action items:
- The registration staff should place a phone call to the patient in order to confirm the patient’s choice, to provide instructions on how to follow up with the insurer, and to offer guidance on transferring medical records in case the new physician is located outside the current practice.
- Registration staff should send a confirmation message to the new physician’s office (through the EHR if the new physician is internal), copying the former pediatrician in the message.
4. Medical Record Update
It is critical to ensure that a transitioning patient’s medical record is fully updated before the transfer of care is complete. When a pediatrician receives the confirmation message as described above, she/he should be prompted to make any necessary updates to the patient’s problem list in the EHR. For patients with complex medical histories, we recommend a conversation between the pediatrician and the patient’s new primary care physician. As Drs. Bensen, Steidtmann, and Vaks write in the LPFCH issue brief cited earlier, communication between incumbent and future providers can significantly reduce gaps in care for adolescents with special health needs.
A version of this operational framework also can be adopted for pediatric patients being seen by family practice physicians. Although a family practice physician may be willing to continue to see a patient into adulthood, it is worthwhile to provide a readiness evaluation to all pediatric patients in order to stimulate thinking about taking responsibility for one’s health. Such an evaluation also offers patients the option of transferring to internal medicine if they so choose.
Benefits of a Standardized Approach
On the surface, a standardized approach may appear to be peppered with challenges. Aside from the patient- and physician-facing barriers described above, a formal policy must be preceded by training of pediatric office staff, configuration of the EHR, and planning for the additional time required to comply with the process. In light of these challenges, leaders may question the merits of adopting a formal policy. However, a discussion of the benefits can effectively reveal the opportunity cost of inaction and highlight why some of these challenges are the very reasons to adopt a transition policy.
First, a clean transition ensures continuity and quality of care as well as the communication of information regarding a patient’s special health care needs to the future care team, thereby minimizing the risk of potentially negative outcomes. Second, guiding the patient and family through the transition will ease the anxiety associated with the process of changing primary care physicians, thus providing comfort and reassurance during an otherwise volatile time in an adolescent’s life. Third, proactively offering adult medicine services that are based within the pediatrician’s health system may result in greater retention of patients. Adolescent patients tend to be limited in their utilization of medical services, and practices that bear financial risk (e.g., ACOs) rely on a healthy membership base to maximize revenues. A deliberate approach can ensure that patients stay within the same health system and perhaps even avoid increased medical costs in the future.
Importantly, given the inevitability that a young adult will move on from a pediatrician’s panel, the institution of a formal transition policy will make the process more clear-cut to physicians and other practice staff, thus actually reducing the administrative burden. Early explanation of this process to patients and their families will make the pediatric staff’s intent explicit, thus curbing the feeling of abandonment while also reminding adolescents that they are facing changes that will require increased awareness and accountability for personal health care.
It may seem easier to accept the status quo and forgo a new approach, as transitions are already occurring, one way or another. We believe that this policy proposal will require a candid discussion with practice staff and leaders about the challenges and benefits of a standard framework. When all is considered, we expect that this framework will resonate with clinical and non-clinical staff alike.